Case 5: Hatchet flap for reconstruction of a defect on the anterior chest wall

Keywords: Hatchet flap, thoracic skin defect, malignant melanoma, reconstruction Authors: Carolina Maria Helena Hilton, MD, Magnus Balslev Avnstorp, MD. Institution: Department of Plastic & Breast Surgery, Zealand University Hospital, Denmark Abstract A 73-year-old man was diagnosed with a malignant melanoma on the left anterior chest wall. According to guidelines he was scheduled for re-excision in 20 mm and sentinel node procedure. The defect following re-excision was too large for primary closure. A Hatchet flap was designed, covering the defect, with a cosmetic and functionally acceptable result. Patient medical history A 73-year-old man with a past medical history including hypercholesterolemia, hypertension, coronary stent and multiple earlier skin cancers (non-malignant-melanomas) was referred to the Plastic Surgery Department at Zealand University Hospital, Denmark, with a suspicion of malignant melanoma located on the anterior left chest wall. The tumor was excised with a 5-mm excision margin according to Danish guidelines (from “Dansk Melanom Gruppe” (the Danish Melanoma Group)). Histology showed a 1,9 mm thick malignant melanoma. The initial excision of 5 mm was not radical. The patient was therefore, according to Danish guidelines, planned for re-excision of 20 mm to the muscle fascia and closure with a local flap and sentinel node procedure. Before and After Patient examination The skin examination showed a cicatrice on the left chest wall, close to the neck, measuring around 30 mm, where skin mobility was not sufficient for direct closure if excised with a 20 mm margin. A lymph node scintigraphy showed two sentinel nodes in the left axilla. The patient was taking acetylsalicylic acid which was continued according to Danish guidelines (from “Dansk selskab for Trombose og Haemostase” (the Danish society of Thrombosis and Hemostasis)) . Pre-operative considerations Direct closure would probably result in reduced neck mobility or at least uncomfortable